Surgery and anticoagulation

[Guest]

It is called evidence-based medicine and the better the evidence, the more sure that you are on the right track. However, sometimes there is just no evidence.

Who would pay millions of dollars to do a study on dental prophylaxis, when the resulting sales would amount to peanuts at best. At worst it might be found out that it didn't work and then the sales would drop to nothing.

The neurosurgeon whose office is down the hall from mine says that he has very little evidence to base his decisions on. This is because it is so hard to recruit a placebo group to have fake operations on their brain tumors, broken necks, etc.

 

[Cris N]

I, for one, would rather be safe than sorry.

Cris

 

[Nancy]

Interesting thing is that antibiotic prophylaxis is indicated for not only heart type problems. On the Breast Cancer site I go to, a woman developed an enormous infection in her newly reconstructed breast after dental scaling. Others followed her post to say they too had had that happen and also some of their relatives who had had hip or knee replacements. All anecdotal for sure, but is something to think about. These people are all now taking antibiotics prior to dental work.

Sounds like bacteria like to head for any disturbed area in the body and set up housekeeping.

Maybe this needs much more investigation on all fronts.

 

[Mary]

Interesting thing is that antibiotic prophylaxis is indicated for not only heart type problems. On the Breast Cancer site I go to, a woman developed an enormous infection in her newly reconstructed breast after dental scaling. Others followed her post to say they too had had that happen and also some of their relatives who had had hip or knee replacements. All anecdotal for sure, but is something to think about. These people are all now taking antibiotics prior to dental work.

Sounds like bacteria like to head for any disturbed area in the body and set up housekeeping.

Maybe this needs much more investigation on all fronts.

I read this in today's newspaper.

"Prosthetic heart valves, hips, knees and other types share one common characteristic. They are all susceptible to bacterial infections . . .not really infection in the classic sense, but bacteria can circulate in the bloodstream, especially after dental work, bowel procedures and so forth. They can land on and stick to the prosthetic material--which has no blood supply to protect itself--set up colonies and cause severe consequences if pockets of bacteria break off and are carried by the blood to other, nonprosthetic sites, such as the brain."

 

[lance]

Why elephants paint their toe-nails red?

Why elephants paint their toe-nails red?

Last summer I was searching the website--Manufacturs and User Facility Device(MAUD) for info on mechanical valve deaths. A patient with a mechanical died one month following a dental appointment from an infection--endocarditis.

Pre-medicate or do not premedicate, stop warfarin or continue reminds me of the old joke about why elephants paint their toe-nails red. They do it to hide in cherry trees. Ever seen an elephant in a cherry tree? No? So obviously it works.

I for one prefer to pre-medicate and heparin bridge for surgery.

Cheers!

 

[RCB]

The history- least we forget

The history- least we forget

We seem to be forgetting the lessons of the past, so let me explain why this is important.

During the fifties, they were still not sure how to use antibiotics, because
they had only been discovered a little over twenties years ago. If you had a fever or something, the protocol said take it till you felt better, then you could stop taking it. It wasn't till the mid-60s they realized that this was actually
harmful to certain diseases like RF. What happened was the antibiotics only killed the weaker strains of the pathogens, leaving only the strongest and most destructive to breed and attack the body? A pt. felt better after a few days of meds. because the body?s immune system thought it had won the battle against the disease( I am simplifying this process for clarity, because it really complex and the medical community still is unsure of how this works) when in fact stopping the antibiotics had really only forced a regrouping of the attacking pathogens. When it was discover what was going on. It led to the stick on label phrase ?Important! Finish all the medication, even if you feel better!?

Another disaster that happened out of ignorance was it was routine during the late ?50s and ?60s to supply anybody who had RF or certain other diseases with a DAILY supply of antibiotics for free. Every month a package arrived with the medication and a short letter explaining why it was necessary to take it. I don?t remember when it stopped, but I do remember a dr. in Texas who was treating me for a fever in the late ?70s, informed me that it was no longer SOP.

An awareness of the overuse of antibiotics began to creep in to minds of the public heath official when they began to see more and more cases of diseases that seemed resistance to the frontline antibiotic drugs. If anyone was paying attention in Ohio( I was because I had my stroke and 3rd HVR, being scared to death of getting this new strain of RF) during the early eighties, there was a higher than normal number of cases of RF that seemed resistance to the normal antibiotic therapy- a so called ?Super Germ!? This prompted a discussion by the infectious disease expert as
to why this was happening. As they began to examine the pt. records they saw a pattern had developed where drs. were over prescribing and wrongly prescribing antibiotics to pts. In many case, drs. admitted to doing it just to make the pt. happy. How many of us have gone to a dr., feeling sick as a dog, only to be told it was a virus and to go home- rest and drink plenty of clear liquids. We were disappointed if we didn?t get some meds. This over prescribing led to antibiotics being less and less effective and the breeding of some pretty nasty ?Super Germs!?

Now the question is which is the bigger problem, the disease or over prescribing that creates even more virulent pathogens. It has never been demonstrated that the use of prophylactic antibiotic therapy (PAT) prevents anything, because pts. still get infections after procedures in which they had taken their medications. One might wonder about what is the harm? The answer...the germ breeding cycle that takes place as PAT becomes routine for more and more people.

With my dentist, I have gotten use to PAT. In life, I have learned to pick my battles and I don?t see this one as decisive or worth the effort- of course, I have been lucky not to be attacked by a ?Super Germ.? Medical standards can change so as to discontinue PAT as SOP for dental procedures, just as they did daily PAT during the ?50s and ?60s.

We must all remember that as medicine is an evolving science, its practice is also an art.

 

[Nancy]

Joe will always pre-medicate for anything invasive, PERIOD. Last time he was in the hospital, he got Klebsiella bacteremia while in the hospital. I can tell you that there were VERY concerned doctors taking care of him. Endocarditis was on everyone's mind. He ended up on 6 weeks of Cipro since he couldn't take anything in the cephalosporins family. This was in September. He's still being tested for any lingering bacterial infection. So far it has come out clean.

It's definitely not worth the risk of getting endocarditis. Valve folks are more susceptible than the ordinary population to developing unusual things. I understand the deal about too much antibiotic prescribing, but this is different.

Why would anyone want to risk getting endocarditis and having an explant or explants and new implant or implants?

Plus those with pacemakers can get bacterial infections in the pacemaker too.

Very messy stuff. If it can be avoided, why not do that instead?

 

[Marty]

?

?

"Infective endocarditis is seldom associated with dental procedures. The efficacy of antibiotic prophylaxis against IE has not been demonstrated. The use of antibiotics carries risk for both the individual patient (from adverse events) and the community at large (by introducing selective pressure on drug resistant organisms). It is time for a thoughtful review of current practices by both the reference organisations and by health care practitioners."

Nancy,This is a summary from a 2001 paper in HEART. The author also notes that chewing and brushing teeth cause bacteremia!

 

[Nancy]

I think they will need to break out from that potential policy, the people who are at the most risk, and I do believe that heart valve implant people are among that group.

It may be just fine and dandy for the general public.

For some reason it was decided many, many years ago that antibiotics were important for heart valve people. Joe was told that in 1977. There must have been a reason to do that. Society wasn't as litigious then as now, so that wasn't as much of a motivation to CMA.

I hate sweeping decisions which don't take into consideration some fine tuning for those at risk.

But then maybe "Heart" doesn't think there is any risk. I would like to hear their exact opinion on whether there is a risk or not for valve patients. It would be interesting to see what they say about that. I would guess there would be a real squirmy answer, if any.

 

[Guest]

What Marty is saying is that every time any antibiotics are given, the bacteria develop some resistance. The more resistance that develops the greater the chance that a person will die of a resistant infection. Our antibiotics are rapidly losing their effectiveness. Once an antibiotic drops below about 75% effective against an organism it becomes virtually useless. Cipro and others are dropping rapidly, in part because it has been believed that they need to be used in situations where there may actually be no need. The really scary part is that there are no - repeat no - unique new antibiotics for anything coming out in the next 10 years. This means that in 2015 we are going to be using the same things that we have now. If we give a little Cipro (or anything else) for every procedure the bugs become resistant. It is also thought that they can transmit this resistant strain to members of the household (by sneezing for instance). We need research to find out if giving Joe antibiotics for cleaning his teeth is increasing Nancy's chance of dying from an infection for which there is no treatment. It sounds a little far-fetched, but this is the type of discussions that are going on among infectious disease specialists. Since the 1940s we have believed that antibiotics would put an end to infections but it just may be the opposite.

Back in the 1940s when bacteria had never been exposed to antibiotics you could give one dose of 4,000 Units of penicillin and a fever would drop from 104 to 98 degrees in 4 hours. Now you could give 20,000,000 units of the same penicillin every 4 hours to combat the same bacteria and it would have about the same effect as running water over your hand.

In the 1960s when bacterial resistance was first becoming an issue, a drug was developed called kanamycin. It worked great but it caused deafness. Fortunately safe drugs came soon after it so kanamycin went into disfavor. Kanamycin is getting another look now for multi-resistant antibiotic infections that are occurring mainly in big medical centers. Will we be willing to accept deafness as an outcome because there are no other antibiotics left?

 

[Marty]

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Nancy, If we valve patients should take antibiotics each time we go to the dentist, we should also take antibiotics before brushing our teeth or eating a steak. Both of these activities have been shown to produce showers of bacteria in the bloodstream.
As Al says we are falling behind in keeping antibiotics one step ahead of the bugs. This makes hospitals particularly dangerous places right now.

Don't worry though, nothing is going to change in the recommendations for dental prophylaxsis- or for the alcohol "swipe" before giving an injection.

 

[perkicar]

INR today=1.5 Recheck in 2 wks???

INR today=1.5 Recheck in 2 wks???

Today I had my INR checked for the first time since my colonoscopy last week. I went back on coumadin the day after my procedure, and took 10 mg the first day, then went back to my 7.5 mg Fri/5 Sat/ 7.5 Sun Mon and Wed/ and 5 on Tuesday.
I was taken aback when the nurse called and told me that the cardio wants me to say on my 7.5 4 days a week and 5 3 days a week and get checked again in 2 weeks!!! I called her back and told her I wasn't comfortable with that, and that I'd be back on Monday to get re-checked and we'd take it from there.
How long should it take for your INR to return to normal after being off for 4 days???
carolyn

 

[Nancy]

I'm not worried about prophylaxis antibiotics for Joe. He'll stay on them, no matter what.

Everyone has the right to make up their own mind as to whether they want certain medical standards or procedures.

Joe will do what he thinks is safe for him, and what he was told was safe for him, and what he continues to be told is safe for him. Others will do likewise using their own convictions.

But I certainly don't want some insurance company bean counters deciding to change things with sweeping decisions, because they think they'll save money, and leaving the sickest of the sick "swinging without a net".

Endocarditis is a GREAT BIG BOOGEYMAN and a potential killer! Joe has enough to worry about, that's for sure.

 

[Guest]

Carolyn,
A week to two weeks in not unusual. I don't like to test people until they have been back on it for at least a week because the INR is not really a significant number before that time.

 

[perkicar]

Carolyn,
A week to two weeks in not unusual. I don't like to test people until they have been back on it for at least a week because the INR is not really a significant number before that time.

thanks Al--that eases my mind somewhat. I still think I will go get re-tested on Monday just to prove to my self that I'mm continuing to trend up. Waiting two full weeks would have had me in a real worried fit!